Power of Attorney For Unmarried Couples
I, [Your Name], residing at [Your Company Address], hereby grant the following powers to [Partner's Name], residing at [Partner's Address], in the event of my incapacity to make healthcare decisions for myself. This Power of Attorney is effective immediately and shall remain valid unless revoked by me in writing.
I. Declaration
I, [YOUR NAME], being of sound mind, willingly and voluntarily do make this POA to provide my Attorney-in-Fact with the authority to make healthcare decisions on my behalf should I become incapacitated.
II. Roles and Responsibilities Transferred to the Agent
Medical Treatment Consent: I authorize my agent to consent to or refuse any medical treatment, surgery, medication, or other healthcare procedures on my behalf, based on the advice of healthcare professionals.
Access to Medical Information: My agent shall have the authority to access my medical records, discuss my medical condition with healthcare providers, and make informed decisions regarding my healthcare.
Choice of Healthcare Providers: My agent is empowered to select healthcare providers, hospitals, or other medical facilities for my treatment, taking into consideration my preferences and best interests.
End-of-Life Decisions: In the event of a terminal condition or irreversible coma where there is no reasonable expectation of recovery, I authorize my agent to make decisions regarding life-sustaining treatment, including the withholding or withdrawal of such treatment, following my wishes as expressed to them or as outlined in any advance directive I may have.
Mental Health Treatment: My agent is authorized to make decisions regarding mental health treatment, including admission to psychiatric facilities and the administration of psychiatric medications if deemed necessary for my well-being.
III. Effective Date
In Witness Whereof, I have executed this Power of Attorney for Healthcare Decisions on [Date].
[Your Name]
[DATE]
[Partner's Name]
[DATE]
Witness Acknowledgement
We, the undersigned witnesses, certify that the foregoing Power of Attorney was signed and declared by [Partner's Name] in our presence and that they appeared to execute the same freely and voluntarily for the purposes therein stated.
[WITNESS NAME][WITNESS 1]
[DATE]
[WITNESS NAME][WITNESS 2]
[DATE]
Notary Acknowledgement
On this day of in the year , before me, a Notary Public, personally appeared [Your Name] and [Partner Name], known to me (or proved to me based on satisfactory evidence) to be the persons whose names are subscribed to the foregoing instrument, and acknowledged to me that they executed the same for the purposes therein contained.
[NOTARY PUBLIC NAME]
[DATE]
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